Charlestown Place At New Albany

Based on interview and record review, the facility failed to ensure respiratory assessments were in place for residents (Resident C, Resident D and Resident H) receiving nebulizer treatments for 3 of 4 residents reviewed for respiratory care.Findings include:1.The clinical record for Resident C was reviewed on 12/8/25 at 11:09 a.m. The resident's diagnoses included, but was not limited to, dyspnea, chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease.The physician's order, dated 10/22/25, indicated the resident was to receive Budesonide Inhalation Suspension (medication administered via nebulizer to make breathing easier), 0.5 mg (milligrams)/2 ml (milliliters) one vial orally via nebulizer twice daily for shortness of breath.The physician's order, dated 10/22/25, indicated the resident was to receive Ipratropium-Albuterol Inhalation Solution (medication administered via nebulizer used to treat bronchospasms), 3 ml every 6 hours for shortness of breath.The clinical record lacked documentation of completed respiratory assessments before, during and after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure monitoring was in place for a resident (Resident H) receiving hemodialysis for 1 of 1 resident reviewed for quality of care.Findings include:The clinical record for Resident H was reviewed on 12/9/25 at 11:21 a.m. The resident's diagnoses included, but were not limited to, end stage renal disease and dependence of renal dialysis. The resident discharged to the hospitalOn 12/9/25 at 10:38 a.m., the resident was observed with a dialysis fistula to his left antecubital space.The care plan, dated 8/31/22, indicated the resident had an alteration in kidney function due to end stage renal disease and dependence on renal dialysis. Nursing interventions included, but were not limited to, check the fistula site for signs and symptoms of infection, no blood pressure or lab draws in the right arm, dialysis center only to access site, observe for post-dialysis hangover including vital signs, mental status, excessive weight gain between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a resident received periodic gradual dose reductions for the anti-psychotic and anti-depressant medications to determine necessity at current dosages for 1 of 5 residents reviewed for unnecessary medications. (Resident 56) Findings include: The record for Resident 56 was reviewed on 8/27/25 at 1:33 p.m., The resident's diagnoses included, but were not limited to, cognitive communication deficit, generalized anxiety disorder, major depression recurrent, insomnia and vascular dementia with other behavioral disturbance. The physician's order, dated 4/4/24 with a secondary order dated 7/22/25, indicated staff were to administer the resident 7.5 milligrams (MG) of Clorazepate Dipotassium Oral Tablet. The resident was to receive one tablet three times a day (TID) to treat anxiety disorder. An anti-depressant was ordered on 4/28/25 for the resident to receive Trazadone HCI (hydrochloriide) 50 mg. The staff were to give one and half tablets to the resident at bedtime, to treat insomnia. Dated 2/17/25, the resident was to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the prevention of UTIs (Urinary Tract Infections) and proper infection control techniques for 1 of 2 residents reviewed for bowel and bladder. (Resident 2)Findings include: During an observation, on 8/22/25 at 12:41 p.m., Resident 2's indwelling catheter tubing was laying on the floor. The resident's urine was leaking onto the floor. The urine was cloudy and pink tinged in color. The resident clinical record indicated the resident currently had a Urinary Tract Infection (UTI).During an observation, on 8/26/25 at 1:30 p.m., Resident 2's indwelling catheter tubing was observed laying on the floor. Light pink urine was observed in the tubing. The record for Resident 2 was reviewed on 8/22/25 at 2:50 p.m. The resident's diagnoses included, but were not limited to, hematuria, dehydration, acute prostatitis, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, urinary tract infection, and urinary retention.The care plan, dated 7/15/25, indicated the resident had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure nutritional supplements were provided to 2 of 9 residents reviewed for skin treatments and nutrition. (Residents 14 and 92)Findings include:1. The record for Resident 14 was reviewed on 8/26/25 at 11:10 a.m. The resident's diagnoses included, but were not limited to, muscle weakness, multiple sclerosis, and vitamin B12 deficiency anemia.The care plan, dated 2/23/25 and revised 7/11/25, indicated the resident had a nutritional problem or potential nutritional problem related to multiple sclerosis, hypertension, gastroesophageal reflux disease, anxiety, and depression, and a pressure injury. On 4/30/25, the resident had a significant unplanned weight loss of 7.4% per month. On 5/13/25, the resident had a significant planned weight gain of 7.9% per month. On 7/6/25, the resident's diet was downgraded under hospice care. The interventions, dated 7/8/25, included, but were not limited to, the resident refused to eat and appeared concerned during meals. Staff were to obtain and monitor the resident's weight monthly and as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to follow up on 2 of 8 Consultant Pharmacy recommendations with the physician for 1 of 5 residents reviewed for unnecessary medications (Resident 56)Finding includedThe record for Resident 56 was reviewed on 8/27/25 at 1:33 p.m. The resident's diagnoses included, but were not limited to, cognitive communication deficit, generalized anxiety disorder, major depression recurrent, insomnia and vascular dementia with other behavioral disturbance. A Pharmacy recommendation, dated 3/24/25, indicated the resident had the following pertinent medication order: Cloazepate Doptassium Oral Tablet 7.5 mg. Staff were to administer one tablet by mouth three times a day for anxiety. Please consider a gradual reduction while monitoring for re-emergence of behavioral and/or withdrawal symptoms.R Review of the physician's orders, between March and October 2025, indicated the documentation was lacking of a response to the Pharmacy recommendation.A Pharmacy recommendation, dated 5/13/25, indicated the following: The Resident had the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure a resident (Resident D) received showers per her preference and failed to ensure a resident (Resident H) received his mail unopened and in a timely manner for 2 of 3 residents reviewed for resident rights.Findings Include:1 The clinical record for Resident D was reviewed on 8/11/25 at 1:08 p.m. The resident's diagnoses included, but were not limited to, depression and anxiety. The annual Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the resident's cognition was intact.On 8/8/25 at 2:40 p.m., the resident was observed sitting up in her wheelchair watching television. The resident's hair was observed to be flat and oily in appearance and her bilateral lower extremities were wrapped with ace wraps. The resident indicated she preferred a shower, but they were bathing her in bed due to her legs being wrapped. She had not had a shower for about a month. She feels so much better when she gets a shower. The resident's shower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a blood pressure medication was held for a resident (Resident K) with out of parameter blood pressures for 1 of 3 residents reviewed for quality of care.Findings Include: The clinical record for Resident K was reviewed on 8/11/25 at 2:16 p.m. The resident's diagnosis included, but was not limited to, hypertension.The care plan, dated 6/9/25, indicated the resident had altered cardiovascular status due to hypertension and medications were to be administered as ordered by the physician.The physician's order, dated 4/5/25, indicated the resident was to receive Lisinopril (medication for high blood pressure) 10 mg (milligrams) daily in the morning. The medication was to be held if the resident's systolic blood pressure (SBP) was less than 110.Review of the July 2025 and August 2025 medication administration record indicated the resident received the medication on the following dates:-On 7/08/25, the Lisinopril was administered to the resident with a SBP of 100-On 7/11/25, the Lisinopril was administered to the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure routine dental services were provided timely for 3 of 4 residents reviewed dental services. Findings Include:1.The clinical record for Resident B was reviewed on 7/16/25 at 1:13 p.m. The resident's diagnoses included, but were not limited to, iron deficiency anemia, anxiety and chronic pain. The annual Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the resident's cognition was intact.During an interview, on 7/16/25 at 4:25 p.m., the resident indicated she had not been seen by the dentist since she admitted to the facility.The admission paperwork, dated 10/5/23, and signed by the resident, indicated Resident B elected for the facility's third partner provider services for dental.The clinical record lacked documentation of a dental authorization/consent or any dental services provided to the resident since admission.During an interview, on 7/16/25 at 3:49 p.m., the Social Services Director (SSD) indicated she had been with the facility since March of this year. There had not been a great system in place…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's (Resident B) admission paper work was completed in a timely manner for 1 of 3 residents reviewed for admissions. Findings include: The clinical record for Resident D was reviewed on [DATE] at 12:15 p.m. The resident's diagnoses included, but were not limited to, dementia and cognitive communication deficit. The progress note, dated [DATE] at 8:46 p.m., indicated the resident was admitted to the facility accompanied by family. The clinical record included the following admission paperwork signed by Resident B's Power of Attorney: - Consent to treat was signed on [DATE] - CPR (cardiopulmonary resuscitation) was signed [DATE] - Bed rail consent with recommendations was signed on [DATE] - Digital photography of wounds consent was signed on [DATE] - Psychoactive medication and recommendations consent was signed on [DATE] - Pharmacy enrollment agreement was signed on [DATE] - COVID-19 disclosure and education was signed on [DATE] -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed the ensure information was provided to the receiving emergency department (Resident B) pending arrival for 1 of 3 residents and failed to ensure the bed hold polices were provided to residents (Resident B, Resident C, Resident D and Resident E) discharged to the hospital for 4 of 4 residents reviewed for transfers/discharges. Findings include: 1. The clinical record for Resident B was reviewed on 3/17/25 at 10:36 a.m. The resident's diagnoses included, but were not limited to, venous insufficiency and diabetes. The progress note, dated 2/25/25 at 10:33 a.m., indicated the resident was transferred to the hospital due to altered mental status. The facility hospital transfer form, dated 2/25/25 at 10:00 a.m., indicated the physician and family were notified of the transfer. The transfer form and clinical record lacked documentation of the hospital notification of the resident's pending arrival and the bed hold documentation was provided to the resident prior to discharge. During an interview, on 3/18/25 at 9:15 a.m., Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure neurological checks were completed on residents (Resident H and Resident K) with unwitnessed falls for 2 of 4 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident H was reviewed on 2/20/25 at 2:37 p.m. The resident's diagnoses included, but were not limited to, cognitive communication deficit, tremors and paraplegia. The progress note, dated 1/23/25 at 2:56 a.m., indicated the resident was found lying on the floor on his right side faced towards the bed. The resident was assessed and his neurological checks were within normal limits. The resident denied any pain or injury. The clinical record lacked documentation of a completed neurological assessment for the fall on 1/23/25 at 2:56 a.m. 2. The clinical record for Resident K was reviewed on 2/20/25 at 3:11 p.m. The resident's diagnoses included, but were not limited to, muscle weakness, dementia with other behavioral disturbance and cognitive communication deficit. The progress note, dated 1/28/25 at 5:29 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure respiratory assessments were completed for a resident and failed to ensure nebulizer equipment was stored appropriately for 1 of 3 residents reviewed for respiratory care. (Resident F) Findings include: The clinical record for Resident F was reviewed on 2/18/25 at 1:48 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and congestive heart failure. On 2/19/25 at 12:35 p.m., the resident's nebulizer was observed on top of the nebulizer machine unbagged. Resident F indicated she received her last nebulizer treatment on 2/18/25 in the evening. The January 2025 medication administration record (MAR) indicated the resident was to receive Ipratropium-Albuterol (medication used to treat COPD), 3 ml (milliliters) via inhalation four times a day at 2:00 a.m., 8:00 a.m., 1:00 p.m. and 8:00 p.m. The clinical record lacked documentation or a respiratory assessment prior to and after the administration of the nebulizer treatments…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a significant medication error did not occur for 1 of 3 residents reviewed for medication errors. (Resident C) Findings include: The clinical record for Resident C was reviewed on 2/18/24 at 11:13 a.m. The resident's diagnoses included, but were not limited to, left-sided hemiparesis/hemiplegia following a cerebral infarction and convulsions. The admission order, dated 2/2/25, indicated the resident was to receive Keppra (anti-convulsant) 2,000 mg (milligrams) twice daily at 3:00 a.m. and 3:00 p.m. The February 2025 medication administration record (MAR) indicated the resident received the Keppra at 3:00 a.m. and 3:00 p.m. The progress note, dated 2/3/25 at 7:47 p.m., indicated the resident was given Keppra 2,000 mg at 8:00 p.m. inadvertently. The progress note, date 2/3/25 at 8:56 p.m., indicated the resident was sent to the hospital for further evaluation. The resident was alert and able to make needs known. The progress note, dated 2/4/25 at 1:55 a.m., indicated the resident was admitted to the hospital for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the physician was notified of a resident's (Resident K) low blood pressure and continuous complaints of shortness of breath for 1 of 3 residents reviewed of notification of changes. Findings include: The clinical record for Resident K was reviewed on 12/27/24 at 9:30 a.m. The resident's diagnoses included, but were not limited to, diabetes, acute respiratory failure with hypoxia, congestive heart failure and hypertension. The resident's September 2024 Medication Administration Record indicated staff were to observe the resident for shortness of breath on day shift, evening shift and night shift. The September 2024 Medication Administration Record indicated the resident was short of breath on 9/3/24 during night shift and on 9/4/24 during all three shifts. The progress note, dated 9/4/24 at 2:01 p.m., indicated the resident reported feeling weak. The resident was assessed with a blood pressure of 80/50 while lying and 93/37 while sitting (a standard blood pressure was 120/80). The resident asked to lay down, because…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the licensed staff accurately assessed a residents' (Resident K) vital signs for skilled charting and obtain vital signs daily for 1 of 3 resident's skilled assessments reviewed for quality of care. Findings include The clinical record for Resident K was reviewed on 12/27/24 at 9:30 a.m. The resident's diagnoses included, but were not limited to, atrial fibrillation, hypertension, congestive heart failure and acute respiratory failure with hypoxia. The daily skilled note, dated 8/30/24 at 12:32 p.m., indicated the resident had the following vital signs: -blood pressure of 113/58 obtained on 8/29/24 at 8:26 p.m. -oxygen saturation of 97% on room air obtained on 8/29/24 at 8:26 p.m. -temperature of 97.9 obtained on 8/29/24 at 8:26 p.m. -heart rate of 68 obtained on 8/29/24 at 8:26 p.m. -respirations 18 obtained on 8/29/24 at 8:26 p.m. The daily skilled note, dated 8/31/24 at 4:51 p.m., indicated the resident had the following vital signs: -blood pressure of 113/58 obtained on 8/29/24 at 8:26 p.m. -oxygen saturation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure staff documented urine output for residents' with indwelling catheters for 3 of 4 residents reviewed for bowel and bladder. (Residents B, F and G) Findings include: 1. The clinical record for Resident B was reviewed on 12/27/24 at 10:07 a.m. The resident's diagnosis included, but was not limited to, obstructive and reflux uropathy. The care plan, dated 8/30/24, indicated the resident had an indwelling catheter and to monitor urine output. The physician's order, dated 9/19/24, indicated to document urine output every day shift and every night shift. Review of the October 2024, November 2024 and December 2024 medication administration records lacked documentation of the resident's urine output on the following dates and shifts: -10/04/24 on night shift -10/13/24 on night shift -10/15/24 on night shift -10/22/24 on night shift -11/16/24 on day and night shift -11/17/24 on day shift -11/20/24 on day shift -12/01/24 on night shift -12/08/24 on night shift -12/17/24 on night shift During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure staff followed a resident's fluid restriction order from the physician, for 1 of 3 residents reviewed for hydration. (Resident K) Findings include: The clinical record for Resident K was reviewed on 12/27/24 at 9:30 a.m. The resident's diagnosis included, but was not limited to, congestive heart failure. The physicians' note, dated 9/1/24 at 12:32 p.m., indicated the resident had gained 5 pounds in 24 hours and to limit the resident's fluid intake to 1,500 cc's (cubic centimeters) in a 24 hour period. Review of the September 2024 fluid intake record indicated the resident consumed the following fluid totals in a 24 hour period: - On 9/2/24, the resident's fluid intake was documented as 2,900 cc. - On 9/3/24, the resident's fluid intake was documented as 1,580 cc. - On 9/4/24, the resident's fluid intake was documented as 2,560 cc. The clinical record lacked documentation of the implementation of the order on 9/1/24. During an interview on 12/30/24 at 4:13 p.m., the Director of Nursing indicated she felt the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the physician's orders were in place for weekly maintenance of the nebulizer equipment (Resident B and Resident H); failed to ensure a nebulizer face mask was stored appropriately and the tubing was dated (Resident B); and failed to ensure physician's orders were in place for routine oxygen administration (Resident K) for 3 of 4 residents reviewed for respiratory. Findings include: 1. The clinical record for Resident B was reviewed on 12/27/24 at 10:07 a.m. The resident's diagnoses included, but were not limited to, asthma and chronic obstructive pulmonary disease. During an observation on 12/30/24 at 10:34 a.m., the resident's nebulizer face mask was lying on the shelf next to the resident's bed, not bagged and undated. The physician's order, dated 9/7/24, indicated the resident was to receive Ipratropium-Albuterol, 3 ml (milliliters) via nebulizer for times a day for shortness of air. The residents clinical record lacked documentation of daily and weekly maintenance of the resident's respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure an order to increase a resident's Lasix (diuretic) was implemented for 1 of 3 residents reviewed for significant medication errors. (Resident K) Findings include: The clinical record for Resident K was reviewed on 12/27/24 at 9:30 a.m. The resident's diagnoses included, but were not limited to, congestive heart failure (CHF) and edema. The admission order, dated 8/28/24, indicated the resident was to receive Lasix 20 mg (milligrams) daily for CHF. The physician's note, dated 9/1/24 at 12:32 p.m., indicated the resident had 1+(plus) pitting edema to her bilateral lower extremities and had a five-pound weight gain in a 24-hour period. New orders were given for the resident to start Lasix 20 mg twice daily for three days then return to the 20 mg daily dose on the fourth day. The September 2024 Medication Administration Record indicated the resident received the medication twice daily on 9/1/24, 9/2/24, and on the morning of 9/3/24. The nurse practitioner follow-up note, dated 9/3/24, indicated the resident reported she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure documentation on the Controlled Drug Receipt/Record/Disposition Form of administered narcotics for 12 of 64 residents observed for medication storage in the 500, 400, and 800 Hall medication carts. (Residents 32, 76, 96, 45, 20, 58, 219, 87, 218, 43, 15, and 77) Findings include: 1. During an observation on 9/9/24 at 8:56 a.m. of the 500 Hall medication cart, the following were identified: Resident 32's tramadol 50 mg (milligrams) Controlled Drug Receipt/Record/Disposition Form had a count of 6 tablets left. The resident's medication card contained 5 tablets of the tramadol. The last dose signed out on the Controlled Drug Receipt/Record/Disposition Form was on 9/8/24 at 9:15 a.m. The record review on 9/10/24 at 1:20 p.m., the physician's order, dated 8/28/24, indicated the resident received the tramadol 50 mg daily for pain. The review of the resident's September MAR (Medication Administration Record) indicated the resident's last dose of tramadol 50 mg was administered on 9/9/24 at 8:00 a.m., by LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure discontinued and expired medications were promptly disposed of during 4 of 7 observations of medication storage. (Medication Carts 300, 400, 800, and Medication room [ROOM NUMBER]) Findings include: 1. During an observation on 9/9/24 at 9:35 a.m. of the 300 Hall medication cart, 2 unused boxes of naloxone hydrochloride with an expiration date of September 2023 were in a drawer in the cart. The boxes had no resident name on them. 2. During an observation on 9/9/24 at 9:09 a.m. of the 400 Hall medication cart, the following concerns were identified: a. Resident 2's discontinued lubricating plus eye drops, with an expiration date of August 2024 were in the drawer. b. Resident 36's Lantus flexpen indicated no open date. There was only 80 units of insulin in the pen. During an interview on 9/9/24 at 9:10 a.m., LPN (Licensed Practical Nurse) 4 indicated the nurse probably forgot to mark the open date, they should write the date on the pen when it was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure kitchen equipment, ceiling vents and the kitchen floor were free from food debris and grease build up for 3 of 3 kitchen observations. This deficiency had the potential to affect 118 residents who received meal trays from the kitchen. Findings include: 1. During the initial tour with the Dietary Manager and the Regional District Manager on 9/5/24 at 8:55 a.m., the following concerns were identified: - One of two ceiling air vents in the dry storage room had gray substance around the vent. The middle slats of the grate cover of the second air vent had a heavy coating of gray dust on the grate. - The walk-in refrigerator had a container of hot dogs on the shelf had a 9/1/24 open date with a 9/3/24 use by date. A container of baked apples had an open date of 9/1/24 with a use by date of 9/1/24. Two sandwiches on a tray had a date of 9/1/24 when they were made with a use by date of 9/4/24. - There was a heavy build up of yellow grease streaks which ran down both sides of the fryer and left side of the steamer. - The top…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a resident was provided a bed and mattress that could accommodate his height comfortably for 1 of 69 resident beds observed for accommodation of needs. (Resident 60). Findings include: During an observation on 9/6/24 at 9:16 a.m., Resident 60 did not have enough room in the bed to move up, and his feet were touching the footboard. His head was all the way to the top of the mattress. During an observation on 9/10/24 at 9:50 a.m., the resident's feet were touching the foot of the bed. The resident indicated he could not even turn over in this bed. RN 5 was present in the resident's room and observed the resident's feet touching the footboard. RN 5 indicated the blisters to the resident's feet were healed and proceeded to uncover the resident's feet and assessed the skin. No blisters were observed. She indicated she did not know if the resident's bed could be extended, but his feet definitely touched the foot board. During an observation on 9/11/24 at 10:46 a.m., the resident's feet were observed touching…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents (Residents E and H) toilets were clean and sanitary for 2 of 4 residents reviewed for resident rights. Findings include 1. The clinical record for Resident E was reviewed on 8/11/24 at 12:13 p.m. The resident's diagnoses included, but were not limited to, hypertension, anxiety and depression. The quarterly MDS (Minimum Data Set) assessment, dated 6/12/24, indicated the resident's cognition was intact. On 8/11/24 at 9:35 a.m., the resident was observed sitting up in her wheelchair in her room watching television. The resident indicated her toilet bowl had not been cleaned in over a week. The toilet bowl was dirty and had a dark black substance in the bottom of it. On 8/11/24 at 9:41 a.m., the Resident's bathroom toilet bowl was observed with a brown splattered substance to the right side of the upper toilet bowl and a dark gray/black substance covered the bottom of the toilet bowl. On 8/12/24 at 9:05 a.m., the toilet bowl in the resident's bathroom was observed with a brown splattered substance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for misappropriation. (Resident C) Findings include: The clinical record for Resident C was reviewed on 8/11/24 at 12:03 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia with agitation, anxiety and depression. The incident report, dated 7/20/24 at 7:01 p.m., indicated upon shift change, the off going night shift nurse, LPN (Licensed Practical Nurse) 9, counted with the oncoming day shift nurse, LPN 10 with a correct narcotic count. On shift change from day shift, LPN 10 counted off with the oncoming night shift nurse, LPN 11 and found the narcotic count for Resident C was missing 5 tablets out of the card. The physician's order, dated 6/27/24, indicated the resident was to receive Norco (Hydrocodone-acetaminophen) 5-325 mg (milligrams) twice daily for pain at 8:00 a.m. and 8:00 p.m. On 8/13/24 at 7:30 a.m., review of Resident C's July 2024 controlled drug record indicated on 7/20/24 at 8:00 a.m., LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow medication administration hold parameters related to a resident heart rate (Resident C) for 1 of 3 residents reviewed for quality of care. Findings include: The clinical record for Resident C was reviewed on 8/11/24 at 12:03 p.m. The resident's diagnoses included, but were not limited to, palpitations, orthostatic hypotension and syncope. The physician's order, dated 7/26/23, indicated the resident was to receive Digoxin 125 mcg (micrograms) daily for palpitations. The medication was to be held for a heart rate less than 60 and to notify the physician. Review of the July and August 2024 medication administration record indicated the following: On 7/08/24, the resident's HR was 47 and the resident's medication (Digoxin) was administered. On 8/11/24, the resident's HR was 55 and the resident's medication (Digoxin) was administered. The clinical record lacked documentation of the physician's notification related to the resident's heart rate less than 60. On 8/15/24 at 1:55 p.m., LPN (Licensed Practical Nurse) 5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure medication administration records and controlled substance records accurately reflected the administration of narcotic medication for 3 of 4 residents reviewed for medical records. (Residents C, F, and H) Findings include: 1. The clinical record for Resident C was reviewed on 8/11/24 at 12:03 p.m. The resident's diagnoses included, but were not limited to, depression and osteoporosis. The physician's order, dated 6/27/24, indicated the resident was to receive Norco (Hydrocodone-Acetaminophen) 5-325 mg (milligrams) twice daily for back pain at 8:00 a.m. and 8:00 p.m. The care plan, dated 11/13/20, indicated the resident needed pain management and staff were to administer the resident's pain medication as ordered. Review of the July 2024 and August 2024 Medication Administration Record indicated, on 7/17/24 at 8:00 a.m., 7/22/24 at 8:00 a.m., 8/9/24 at 8:00 a.m. and 8/10/24 at 8:00 a.m., the resident received the twice daily Norco (pain medication). The July 2024 and August 2024 controlled substance record lacked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the nursing staff followed medication parameters for 1 of 4 residents reviewed for quality of care. (Resident C) Findings include: The clinical record for Resident C was reviewed on 6/25/24 at 1:38 p.m. The resident's diagnosis included, but was not limited to, hypertension. The care plan, dated 11/14/22, indicated the resident had impaired cardiovascular status due to hypertension and medications were to be administered as ordered by the physician. The physician order, dated 1/23/24, indicated the resident was to receive Lisinopril (medication for high blood pressure) 10 mg (milligrams) daily. The medication was to be held if the resident's SBP (systolic blood pressure) was less than 100 or if the resident's heart rate was less than 60. The April 2024 MAR (medication administration record) indicated the medication was administered as follows: - On 4/03/24, the resident's heart rate was 59 - On 4/04/24, the resident's SBP was 95 - On 4/05/24, the resident's SBP was 85 - On 4/12/24, the resident's SBP was 90 The May…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the physician was notified of a resident's (Resident B) loose stool for 1 of 3 residents reviewed for change of condition. Findings include: The clinical record for Resident B was reviewed on 5/2/24 at 9:26 a.m. The diagnoses included, but were not limited to, dementia and cognitive communication deficit. Review of the October 2023 bowel record for Resident B indicated the resident did not have any loose stools. Review of the November 2023 bowel record for Resident B indicated the following: - On 11/19/23 at 2:03 p.m., the resident was incontinent with a medium loose/diarrhea stool - On 11/19/23 at 8:52 p.m., the resident was incontinent with a large loose/diarrhea stool - On 11/20/23 at 3:50 p.m., resident was incontinent with a large loose/diarrhea stool - On 11/21/23 - the resident did not have a bowel movement - On 11/22/23 at 2:08 p.m., the resident was continent with a large loose/diarrhea stool The clinical record lacked nursing documentation or any follow up or physician notification on the resident due to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a resident's (Resident D) room was free of potential hazards and education was provided to the resident (Resident D) on the risks of negative outcomes secondary to potential hazards for 1 of 3 residents reviewed for accidents. Findings include: The clinical record for Resident D was reviewed on 5/2/24 at 2:04 p.m. The diagnoses included, but were not limited to, diabetes, major depressive disorder and paraplegia. The quarterly MDS (Minimum Data Set) assessment, dated 3/17/24, indicated the resident's cognition was intact. The nurse's note, dated 5/1/24 at 11:04 p.m., indicated Resident D turned his call light on for assistance. The off-going nurse, RN (Registered Nurse) 5 stopped by his room to see what the resident needed. The resident was lying on his phone charger cord, in the bed, which was plugged into an extension cord. The resident stated All I did was move over in the bed and it just stated to burn me. It felt like a bee sting. The resident had a blister formed on his right upper back side. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a plan of care was in place for a resident's (Resident D) refusal of care for 1 of 3 residents reviewed for for care plans. Findings include: The clinical record for Resident D was reviewed on 2/21/24 at 10:30 a.m. The diagnoses included, but were not limited to, dementia and stage 3 (full thickness tissue loss) pressure ulcers to the coccyx, left buttock and right buttock. The progress note, dated 1/28/24 at 1:47 a.m., indicated the resident had a shearing area to the left and right buttocks. The wound note, dated 1/29/24 at 3:50 p.m., indicated the areas were noted to be Stage 3 pressure ulcers. The wound physician note, dated 2/1/24, indicated the resident had a Stage 3 to the left buttock which measured 2.3 cm (centimeters) in length, 2.4 cm in width with a depth of 0.1 cm ; Stage 3 to the coccyx which measured 1.1 cm in length, 0.5 cm in width with a depth of 0.1 cm; and the Sage 3 to the right buttock which measured 2.5 cm in length, 1.2 cm in width with a depth of 0.1 cm. During an interview on 2/21/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure residents' (Residents D and E) treatments were completed, as ordered by the physician, for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident D was reviewed on 2/21/24 at 10:30 a.m., The diagnoses included, but were not limited to, stage 3 pressure ulcers (full thickness tissue loss) to the coccyx, left buttock and right buttock. The care plan, dated 8/17/23, indicated the resident was at risk for impaired skin integrity and to perform treatments as ordered by the physician. The February 2024 treatment administration record (TAR) indicated staff were to cleanse the resident's coccyx, left buttock and right buttock wounds with normal saline, apply calcium alginate and cover with a foam dressing daily for wound care. The February 2024 TAR lacked documentation of treatment completion on 2/3/24, 2/6/24, 2/8/24, 2/10/24 and 2/18/24 for the left and right buttocks; and 2/3/24, 2/6/24, 2/8/24 and 2/10/24 for the coccyx. The February 2024 TAR indicated, dated 2/11/24 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/23/24 at 2:02 p.m. The diagnoses included, but were not limited to, right shoulder pain, paraplegia, neuropathy and low back pain. On 1/24/24 at 12:45 p.m., the resident was observed resting in bed with his eyes open. He had no signs of pain or discomfort. Resident B indicated he had not missed any doses of his pain medication. The incident report, dated 12/15/23 at 5:01 p.m., indicated staff were unable to locate the resident's pain medication or the controlled drug record. The physician's order, dated 11/30/23, indicated the resident was to receive Oxycodone (narcotic pain medication) 10 mg (milligrams) every for hours for pain. Review of the pharmacy packing slip, dated 12/5/23, indicated 90 tablets of Oxycodone was delivered to the facility and signed for by LPN (Licensed Practical Nurse) 4. The clinical record lacked page 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to implement and update a resident's plan of care after the resident displayed aggressive behaviors and a resident to resident altercation for 1 of 3 residents reviewed for Dementia Care. (Resident D) Findings include: The record for Resident D was reviewed on 8/21/23 at 9:20 a.m. The diagnoses included, but were not limited to, disorientation, dementia with behavioral disturbance, anxiety disorder, altered mental status, depression, and injuries of the head. The Quarterly MDS (Minimum Data Set) assessment, dated 4/17/23, indicated the resident was severely cognitively impaired. The resident's care plan lacked documentation of the resident on resident altercation that occurred on the dementia unit. The behavior note, dated 2/5/23 at 6:22 p.m., indicated the resident was verbally abusive to staff and other residents. He did not want them to sit any where near him in the common area, talk, or want them to watch television. Staff had tried to redirect the resident, but the resident continued to not want them any where around…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure appropriate social services follow-up after unwanted and inappropriate behavior interactions from a resident with behavior concerns for 8 of 9 residents reviewed for Social Services. (Residents 24, 80, 320, 57, 20, 60, and 86) Findings include: 1. The nurse's note, dated 11/25/22 at 9:33 a.m., indicated while rounding on Resident 86 due to his behaviors, the resident's roommate (Resident 24) indicated he felt unsafe in the room with Resident 86 and wanted to be dressed and taken out of room. He did not want to return to the room while his roommate was in the room. He was immediately dressed and removed from room and placed in common area. The resident was mobile in a wheelchair. The Significant Change MDS (Minimum Data Set) assessment, dated 6/26/23, for Resident 24 indicated the resident was moderately cognitively impaired. He required extensive assistance with bed mobility and extensive assistance for transfers. The record lacked documentation of any social services follow-up for Resident 24. 2. The nurse's note,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure the dishwashing equipment was at an appropriate temperature to disinfect dishes. This had to potential to affect all 115 resident residing in the facility. Findings include: During an observation on 7/24/23 at 9:39 a.m., the dishwasher's temperature gauge read 110 degrees F (Fahrenheit) during the wash cycle and the rinse cycle read 109 degrees F. During an interview on 7/24/23 at 9:45 a.m., the Dietary Manager indicated he was not happy with the dishwasher temperature. During an observation on 7/26/23 at 12:53 p.m., the dishwasher's temperature gauge read 110 degrees F on the wash cycle and the rinse cycle read 108 degrees F. During an interview on 7/26/23 at 12:55 p.m., the District Manager indicated the low temperature was due to the staff running the hot water on the dishes, while running the dishwasher. He educated the staff on not using the hot water while using the dishwasher. During an observation on 7/31/23 at 8:27 a.m., the dishwasher label indicated the following: -Water temperature minimum of 120 degrees.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were offered pneumococcal vaccinations as recommended by the CDC (Centers for Disease Control) for 3 of 5 residents reviewed for pneumococcal immunizations. (Residents 377, 18, and 22) Findings include: 1. The record for Resident 377 was reviewed on 7/28/23 at 8:48 a.m. The record indicated Resident 377 was [AGE] years old and had received PCV13 (pneumococcal conjugate vaccine) on 6/4/22. The record lacked documentation of any offer for the resident to receive the recommended second dose of either PCV20 or PPSV23 (pneumococcal polysaccharide vaccine) after one year as recommended by the current CDC guidance. 2. The record for Resident 18 was reviewed on 7/28/23 at 8:50 a.m. The record indicated Resident 18 was [AGE] years old and had received one dose of PCV13 on 4/2/21. The record lacked documentation of any offer for the resident to receive the recommended second dose of either PCV20 or PPSV23 after one year as recommended by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to inform the resident's family in advance of the treatment risks, benefits and additional options for psychiatric services and failed to obtain a physician's order for treatment prior to the implementation of psychiatric services for 1 of 24 residents reviewed for resident rights. (Resident 110) Findings include: The clinical record for Resident 110 was reviewed on 7/26/23 at 12:36 p.m. The resident's diagnoses included, but were not limited to, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, delusional disorders, amnesia, anxiety disorder, and major depressive disorder. The admission MDS (minimum data set) assessment, dated 2/20/23, indicated the resident was severely cognitively impaired. The quarterly MDS, dated [DATE], indicated the resident was severely cognitively impaired. A nurse's note, dated 5/15/23 at 1:40 p.m., indicated a call was placed and message left for the resident's family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the Minimum Data Set assessments were correctly documented for behaviors for 1 of 25 residents reviewed for accuracy of assessment. (Resident 86) Findings include: The record for Resident 86 was reviewed on 7/26/23 at 11:37 a.m. The diagnoses included, but were not limited to, developmental disorder of speech and language, anxiety disorder, altered mental status, and lack of expected normal physiological development in childhood. The care plan, dated 7/1/21 and revised on 4/29/22, indicated the resident had behavior problems of expressing frustration, agitation, anxious and restless by throwing items and making disruptive sounds. The nurse's note, dated 3/9/23 at 1:39 p.m., indicated Resident 86 had been resting abed, had pulled the call bell out of wall and thrown it across the room, had taken his glasses and thrown them across the room, had hollered out several times, resident yells and had attempted to hit the nurse and CNA (Certified Nursing Aide) while providing incontinent care. He was offered a snack and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer prevention interventions were provided as indicated in the resident's care plan for a resident with a known history of pressure ulcers for 1 of 7 residents reviewed for pressure ulcers (Resident 34). Findings include: The record for Resident 34 was reviewed on 7/28/23 at 9:15 a.m. The diagnoses included, but were not limited to, lack of coordination, unsteadiness on feet, muscle weakness, type 2 Diabetes Mellitus, hyperglycemia, dysphagia following cerebral infarction, left flaccid hemiplegia, Stage 3 pressure ulcers, vascular dementia, cognitive communication deficit, osteoarthritis, and the presence of tendon and bone implants. The Quarterly MDS (Minimum Data Set) assessment, dated 7/10/23, indicated the resident was severely cognitively impaired. She required extensive assistance of 2 staff members for bed mobility and transfers. The care plan, dated 8/19/19 and last revised on 7/15/23, indicated the resident had an unstageable pressure area to the sacrum, which was a Stage 3. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure appropriate fluid status management related to administration of diuretics, clarification of orders for duplicate therapy, and weight monitoring for 1 of 3 residents reviewed for fluid status management. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 7/26/23 at 1:07 p.m. The diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), pleural effusion, CHF (congestive heart failure), dyspnea, pneumonia, acute respiratory failure, ischemic cardiomyopathy, chronic atrial fibrillation, nonrheumatic aortic valve insufficiency, Stage 3 chronic kidney disease, presence of automatic cardiac defibrillator, presence of cardiac pacemaker, cardiac arrhythmia, edema, hypertension, chronic pulmonary edema. The care plan, dated 12/31/18 and last revised on 5/22/23, indicated the resident had an alteration in his respiratory status due to COPD, respiratory failure, CHF, pneumonia, shortness of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to adequately implement social services to address the continuous behavior of crying, pacing, agitation, restlessness and adjustment to the secured unit for a resident with a diagnosis of dementia for 1 of 3 residents reviewed for Dementia Care. (Resident 110) Findings include: The clinical record for Resident 110 was reviewed on 7/26/23 at 12:36 p.m. The diagnoses included, but were not limited to, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, delusional disorders, amnesia, anxiety disorder, and major depressive disorder. A physician's order, dated 2/10/23, indicated the resident received Ativan 0.5 mg (milligrams) one tablet two times a day for anxiety. The medication was discontinued on 2/12/23 and a new order for Lorazepam 0.5 mg one tablet every 12 hours PRN (as needed) was received. This medication was then discontinued on 2/24/23 by the psychiatrist. A nurse's note, dated 2/10/23 at 1:38 p.m., indicated the resident arrived on the secured unit with family. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.